You have to love insurance coverage. When January 1 came around, a number of our patients learned the unfortunate news that their co-pays had jumped anywhere from $10-$50. (The increase from $0 to $50 was an isolated event; however I'd estimate the average rise being around $15). This was a surprise for the majority of our patients, and the most regrettable aspect is the effect the increase in co-payments has had on their plans of care.

On patient particularly stands out. Her start of care was in November following a repeat rotator cuff repair and SAD. She's been through the wringer. She works as part of the dietary team in a local hospital and is responsible for delivering meals to patients throughout the day. Her original injury, in June, occurred at work while she was pushing one of those massive carts around. She's been out of work since that time, collecting only 60% pay.

We were finally cleared to begin some more rigorous return-to-work activities at the end of December and started to make some major progress with her ability to manage occupational demands. Then she came in on January 2 to learn that her co-pay had increased to $40. Realizing that she and her family have had a hard enough time getting by on 60% pay, I knew there was no way she'd be able to continue even twice per week. We decreased the frequency to once per week, and I just hope it's enough to get her to the point she needs to reach when she returns to work at the end of this month.

To find a positive in this situation, now more than ever we as physical therapists need to provide the most efficient, evidence-based care. It's what we should be doing all the time, but the consequences are becoming greater and greater. I imagine these situations are not going to get better, and we need to adapt with the current climate in order to maintain our significance.

I guess it's inevitable that in a city (Pittsburgh) with cold, snowy winters, there are bound to be a ton of cancellations in the winter months. Add that on to an already light caseload (which I assume is also related to the winter months), and it can make for some very slow days. Take last Friday, for example. I only had six patients on my schedule for the day, and a grand total of two showed up.

My clinical instructor, with some amazing foresight, knew this would happen so we started to populate a "lessons" list that we can work on when the clinic is dead. It started with basic modalities like setting up cervical traction and different NMES parameters. Then we decided to try a functional electrical stimulation device for treating foot drop, which was useful since there's a patient who may benefit from it in the next few weeks.

The list has expanded to include complex gait assessment and appropriate techniques, prosthetic education, amputee-specific interventions, and other more functionally based measures. We're even focusing on manual therapy techniques, tweaking my hand placement, and discussing more advanced interventions. I've also managed to sneak a few boards questions into the mix, which is helpful during the study process.

Despite the excessive amount of downtime, I feel like I'm learning some incredibly valuable clinical assessment and intervention skills in a very learning-friendly environment. I appreciate the effort that my clinical instructor has put forth to make the best use of our time. I encourage anyone who is a CI for a full-time student to take a similar approach to recognizing learning opportunities -- it won't go unnoticed!

With 2014 on the horizon, I'll be seeking employment somewhere in the physical therapy field very shortly. The real question is -- when is it appropriate to start applying for jobs? I imagine that a student who has passed the boards is much more marketable, which means I'm looking at the middle of February if all goes as planned and I don't fail.

Between now and then, I have a lot of work to do. Step one is likely updating my resume. I guess it's time to get rid of the pre-PT school volunteer experiences, job history, and undergraduate honors. But what do I add? Every single clinical I've ever had, even the part-time ones? My gut tells me to highlight the important ones.

Step two -- I'm going to create a profile on Monster.com or an equivalent employment website. I've never created a Monster profile, but I think it could help to explore the job market and get a better understanding of opportunities, regional differences, and salaries. Step three -- figure out what in the world to expect for a starting salary. This is something I've avoided asking the majority of my clinical instructors out of respect, but I'm unfortunately clueless about what to expect for an entry-level PT position.

As this is my first true career, I'm new to the formal process of applying, interviewing, and accepting positions. On top of that, there's a lot more at stake. Benefit packages, opportunities for advancement, taxes... it's almost overwhelming. I think I have a lot of work and research to do before I feel prepared to fully tackle this.

When I take a step back and think about the concept of "personal space," I realize that it doesn't exist in the PT world. Three years ago, if I had to poke around a stranger's greater trochanter or get up close and personal for a transfer, I would have heard that natural alarm in my head saying "you're way too close to this person right now... and it's awkward." I'm amazed at how desensitized I've become. That being said, recognizing this type of physically based interaction also makes me realize that for patients, it may be something completely foreign.

There's no getting around the fact that PT has to be hands-on. I remember reading an article about expert vs. novice clinicians, and one of the major differences was that experts had a lot more "hands-on" time. It's important. For a patient, I can imagine that the 10 minutes you have between first introduction to the therapist and the start of the physical exam is surely not enough time to feel comfortable with a complete stranger trying to find your PSIS. I've made an effort lately to say a sentence or two about the way PT works, why and when I'll be putting my hands on the patient, and what I'm looking for. It seems to help, but I'm sure it's still slightly alarming for some patients.

Inevitably, there are going to be people who just don't feel comfortable with the invasion of personal space. In that case, I'm not sure what to do. I think hands-on skills and interactions are an invaluable piece of what we do, so I've taken the approach that it's my responsibility to make people comfortable and knowledgeable about what to expect during their physical therapy course.

The further I get into my boards study schedule, the more concerned I am about some of the content included in the review book. Maybe some of my concern is related to the fact that I'm first covering topics that I feel least comfortable with -- cardiopulmonary and modalities. But I'll be honest, there are some topics in the book that I've never seen before in my life.

Should I be concerned? Did I somehow miss this portion of PT school? Or is it just impossible to cover every single piece of information so I should expect to come across new subject matter while I'm studying for the biggest exam of my life, which is seven short weeks away? It's a little bit disconcerting, especially because I haven't been cruising through the curriculum. I didn't skip class, I tried by best to pay attention, and still I've never heard of the percussion test for peripheral venous circulation (among others).

There is also the aspect of practice exams. I've heard a lot about the difficulty level of the O'Sullivan tests, which are from the book I've been using to study. According to some people, the tests are more difficult than the boards. But that didn't necessarily give me much comfort when I took the first test and got a 73%. Yikes. Suddenly, I feel like I'm never going to have enough time to prepare for this exam, let alone get to the point where I'll feel like I'm going to pass.

I'm starting to realize that laying the groundwork for discharge could be one of the most important pieces of communication that a PT (student or clinician) tackles with her patients. Though I haven't run into it yet, I can foresee some tricky discharges in the future with patients and their families who would prefer to continue with therapy indefinitely.

This is a topic that my clinical instructor and I have recently visited. She gave me some very valuable advice that has to do with "planning ahead" to ensure that both patients and their families understand when discharge will take place. She said that from the beginning, it can be helpful to emphasize that we need to see objective progress in order to justify the continuation of therapy.

Part of the conversation has to do with explaining outcome measures, their meaning, and their application to a patient's recovery. The other essential piece of communication has to do with measuring those outcomes frequently and providing continual input to the patients and their families regarding progress or, in some cases, plateau.

Unfortunately, I currently have two patients with whom I haven't applied this advice and I anticipate some difficult conversations in the future. That being said, I've tried my best to start incorporating these principles into our sessions (ever so elegantly). It's a great lesson to learn as a student, and very valuable piece of advice to take forward in my career.

It's the age-old question for PT students on rotation around the holidays -- will I be expected to work? There's inevitably that awkward point when the issue finally surfaces and you find yourself trying to test the waters mid-conversation. Someone brings up Thanksgiving, which spins into the winter holidays, and all of a sudden you're in a panic as you realize that for the first time, you won't get three weeks off for winter break. Will they really need me? Do they really expect me to be here?

All of a sudden, you want to throw away what you've worked for since the start of the clinical as the real world hits you in the face. My own caseload? Take it back. A taste of independence? I'd rather not. My acceptance as a coworker rather than a student? Don't need it.

And that's just the outpatient side. I really feel badly for my friends who are in the hospital. What happens then? There's an even more awkward conversation to be had about working Christmas Day, New Year's Day etc. During my first rotation, I worked the 4th of July. It was a conversation I didn't feel like having, so I followed my clinical instructor's schedule and watched the tailgates from a hospital window. It's a whole new ballgame around the winter holidays. There's a little more at stake.

It's depressing to face the working world and realize that for the rest of your life, there won't be a conversation to be had. We're hanging onto the last piece of our youth! As for me, my family lives close by so working near the holidays won't be anything more than a realization that the real world is just around the corner. Thankfully I'll still get to spend plenty of time with them. As for the rest of the joys of being a student, I think they're long gone. Goodbye, holiday ski trips. Goodbye, lazy weeks.

In transferring from inpatient rehab to a local outpatient PT clinic, I have the unique opportunity to see patients throughout their course of recovery. When I arrived to my current clinical site, I recognized at least three patients who had been on either the brain injury or spinal cord injury units when I was completing my clinical rotations at the hospital, and I just found out that one more is due to be evaluated in the next month.

One particular case stands out. A patient currently on my caseload was completing his second course of inpatient rehab when I was placed on the brain injury unit in July. I ended up transferring to another clinical before he was discharged, however I remember exactly how he was doing when I left.

I'll be honest -- I saw him on my schedule for outpatient PT and wasn't really sure what to expect. He had a very complicated medical course including a significant brain injury as well as orthopedic complications (including a transfemoral amputation). I'm happy to say he's doing better than I could have imagined. It's a very valuable experience to see a patient progress through therapy, recovery, and even compensation. Seeing the bigger picture and the protracted process of therapy gives a new perspective to which skills are important "when," and what a patient truly needs to achieve in order to progress to higher-level activities.

I'm looking forward to the other patient who will be evaluated at the end of this month. He was one of my favorite and most exciting patients to treat on the spinal cord injury unit. I got to know both he and his family very well during the five weeks that we worked together, and his wife sent me an e-mail yesterday to let me know they would be seeing me on the "outpatient side." They even said they're excited to get to work with me again. I'm sure his continued course of PT will be another valuable experience in how patients recover and I'm excited to see the progress he has made in the month since I left the hospital.

I just finished my second week at an outpatient clinic where I see a great variety of patients. I'd say it's split 50/50 between orthopedic and neurologic diagnoses. The caseload diversity is going to be a great learning experience. But until I feel up to speed again with my outpatient skills (especially my evaluation skills), I anticipate a few rocky patches and early breaking points.

As a student six months away from graduating, I know there are certain expectations about where you should be in the spectrum of clinical development, particularly with the orthopedic population. However I haven't completed a full ortho eval in about a year-and-a-half and to be honest, we hadn't even covered our entire musculoskeletal coursework at that point. So when I looked at my schedule for the week and saw shoulder, knee, low-back, and cervical initial evaluations, I felt completely overwhelmed.

I managed to tackle it all, but reflecting on the week I'm starting to feel like the caseload is getting away from me. I don't feel like I've had time to think about each of these patients or develop a plan of care that I feel comfortable progressing. It's always a tough situation to be in as a student because you want to be challenged and you want your colleagues to trust you with as many responsibilities as possible, but there's a very thin line between juggling those responsibilities and letting it all come crashing down.

In case you haven't followed the past few blogs, I started a new clinical on Monday after having spent six months in an inpatient rehab setting. I'm now interning at an outpatient center where the patient population spans the entire gamut -- orthopedics, neurological, cardiopulmonary, post-op, chronic pain, worker's comp etc. With all of the variation, I feel like I have to go back to the very basics of musculoskeletal and cardiopulmonary PT just to be semi-functional and relatively independent.

One of the more intimidating parts of this switch is that I understandably am being held to a higher standard with higher expectations, which means the facility is looking to build my caseload as quickly as possible. I felt overwhelmed just talking about my schedule for the upcoming week. I feel completely unprepared on certain days, which is a significant shift from how I felt when I left the hospital. In some ways, I thought I would have been able to accept an entry-level position with just a bit more practice. That's definitely not the case anymore.

One of the biggest adjustments I've had to make has to do with my evaluation skills. Whereas in the hospital a lot of the evaluative tools were screening measures for all systems, the outpatient world is much more focused on the specific musculoskeletal details causing or complicating certain deficits. I can't tell you the last time I measured someone's knee flexion ROM in prone. I can't imagine how many small details I've forgotten that are going to take some time to remember and implement regularly, which for now means my confidence levels are going to plummet back to the depths of second-year Lauren. Yikes.

It's been about six months since I've written anything other than a progress note or a blog, and about as long since I've sat in a four-hour lecture. On Saturday, I sat in eight hours of a conference, and Sunday I completed a 20-page "final" project. (Final is in quotes because I have to repeat the same thing in four months). It's amazing how quickly your student capabilities can be reduced to nothing. I couldn't sit still for more than 20 minutes in the conference, and I'm struggling to look at the computer screen anymore. I used to be a champ!

The submission of this paper marks the halfway point for my final year of PT school, which subsequently means I'm inching closer and closer toward big-kid health insurance, paychecks, mortgages, responsibilities, boards, marriage, life... yikes. Sometimes I forget about this, and other times (like now) it hits me right in the face. I have six months left at an outpatient clinic to hone as many skills as possible before I'm expected to care for my own patients. Suddenly six months doesn't feel like enough time.

I wonder if this constant fluctuation between confidence and panic is normal. Sometimes the panic is preceded by something obvious -- exams, clinical failures, and student loan statements. Other times, it just pops out of nowhere. The confident times seem to outweigh the episodes of panic, which I take as a good sign. I wonder when I'll feel like I'm ready for all of this. Maybe once I pass the boards? Accept my first job? Or is it going to take a bit of sink-or-swim until I feel like I'm ready to be on my own? This nervous excitement makes me think I picked the right career, but nonetheless it can be unsettling.

I've dealt a lot with the "c" word lately -- cancer. On both a personal and professional level, I've had an up-close look at the effects of the disease on patients, families and healthcare professionals. In the world of PT school, we covered cancer interventions and suggested case management. That being said, I think it can be very difficult to create plans of care for patients (and their families) who have been diagnosed with cancer. On the spinal cord injury unit, I've seen two patients who were in inpatient rehab due to spinal metastases. (It goes without saying that this complicates things -- not only are you dealing with cancer, but also with teaching a patient how to live with a spinal cord injury).

Discharge planning has been difficult for a number of reasons, as I'm sure it can be across the board when the prognosis is unpredictable. Particularly related to spinal metastases, it can be tricky to determine equipment needs when you aren't sure how the patient is going to present in, say, four months. In one case, the patient needed a customized wheelchair, but we weren't sure if he'd be able to propel it by the time the fitting, order and delivery were completed. Even family training was complicated. When we saw him, he was able to transfer independently. However, considering he was going to have another around of radiation therapy after he left, we weren't sure if his functional status was going to change by the time he and his wife got home.

I will say that one great lesson I've taken away from these cases has been related to my interaction with the hospice agency. They were unbelievably helpful with discharge planning, acquiring equipment, and follow-up needs. As a PT, I don't expect to work with them very frequently, but I was happy for the experience and to be exposed to all their agency has to offer. I'm curious if anyone out there has a protocol in place for patients with cancer, of if you have found any helpful interventions and planning tools to make the therapy process as successful as possible.

Three different events have come up in the past week that make me wonder about the world of "light duty" and injuries. If you're reading this, I'm assuming you have some career connection to physical therapy and therefore realize that ours are not the type of jobs where you can work through injuries -- sometimes even minor ones.

For example, a classmate of mine is faced with the decision whether or not to proceed on the surgical route for a herniated disc. Conservative approaches (including PT) have failed. If he decides to get surgery, there's a chance he won't be able to complete his clinical rotations as scheduled. He will of course graduate, but it's remarkable to think that a medical decision to prevent long-term impairment could potentially complicate and delay his graduation. But it's the nature of what we do.

An even more extreme example is a coworker of mine who is pregnant and recently was put on a 5-pound lifting restriction for the duration of the pregnancy, which is five months. As much as the hospital would like to accommodate her, they just can't guarantee it. I know it's not an injury, but it's another example of the physical requirements of our profession.

And then there's me. I just ran a 9-mile race, and now I can't walk up the stairs. Not that it's a major injury, but I'm a little bit concerned about how I'm going to get through the next few days. If I were in most other careers, it wouldn't even be an issue. To think that in the future I may have to take PTO for something like this is eye-opening.

Working on the spinal cord injury unit, I often find myself treating patients whose functional recovery we can't predict. As I've taken the lead on more of these cases, one of the most significant challenges I face is finding a balance between providing encouragement and giving people false hopes about their progress and recovery. Anyone in any setting can sympathize with these types of situations.

By nature, I am an excitable person and I'll be the first one to admit that my reaction to even slight improvements can be excessive. At times, the excitement is warranted -- only a few days after injury, a patient with an incomplete spinal cord injury begins to exhibit trace movement in some muscle group. Or a patient who is withdrawn and not buying into his recovery has a great session, and I do everything I can to demonstrate to that patient he is making wonderful progress. Other times, I'll reflect on my reactions and realize that my encouragement may be crossing that line into unwarranted excitement and false hopes.

It can be very difficult on the spinal cord injury unit because sometimes, given these life-changing and often heartbreaking circumstances, all you want to do is find some sort of positive light to shed on the situation. Particularly for those people who are having a hard time adjusting. It just breaks my heart to see them "give up," so my natural reaction is to counteract their negativity with overt positivity.

Like I said, I'm starting to realize this isn't necessarily the best approach. But at the same time, I don't know what is. Is this just another one of those skills that develops over time, or is this a personality flaw that is going to haunt me throughout my entire career? It's a tough predicament, and I'm just hoping to find a better way to walk the fine line between encouragement and false hopes.

Having the opportunity to spend three months at one clinical site has meant that I've seen a lot of my patients through their entire course of inpatient rehab care. And as I've taken on more of my own caseload, I've been their primary PT. By chance, there has been a lot of turnover during my time on the spinal cord injury unit, so I've seen even more patients than I expected. Of those patients, there have been many whose families I became close to and who I'd like to keep in touch with.

Recently, one patient was discharged who lives close to where I went to undergrad and to where my boyfriend's family is from. We spent a lot of time talking about the area, fun outdoor activities, and mutual likes/dislikes of the local restaurants. When he and his wife were getting ready to leave, they offered an open invitation to visit them any time I'm in their neck of the woods (which is quite often). They are two of the most wonderful people I've ever met, and I would love to see them again. But there's always that lingering question of what is and is not appropriate for patient-therapist interactions.

I personally don't see anything wrong with grabbing a cup of coffee with the two of them at some point.